Estes são os slides do Exame Físico Neurológico que apresentei no evento da Liga de Neurologia e Neurocirurgia da Ulbra em 215. Mais slides no slideshare e no blog da nossa Neuroliga Ulbra: http://neuroligaulbra.blogspot.com.br/ A Liga de Neurologia e Neurocirurgia traz um evento inovador: Uma monitoria de Neurologia Clínica diferente, focada nas dúvidas -e curiosidades- dos acadêmicos. Teremos 5 temas, em 5 quintas-feiras às 12h pelos monitores da Neuro e membros da NeuroLiga e pelos nossos professores experts da Neurologia I e II presentes. Quintas-feiras, 12h-13h 26/03 – Exame Físico na neuro 16/04 – Tumores Cranianos 07/05 – Cefaleia28/05 – AVC 18/06 – Infecções SNC e S. de Guillain Barré http://neuroligaulbra.blogspot.com.br/2015/04/revisando-topicos-essenciais-em.html

2. Um obrigado ao Charlie Goldberg,
M.D. Professor of Medicine, UCSD
SOM cggoldberg@ucsd.edu

3. Elements of The Neuro Exam
• Cranial Nerves
• Motor – bulk, tone, strength
• Coordination – fine movements, balance
• Sensation – pain, touch, position sense,
vibration
• Reflexes
• Gait
*Mental status covered elsewhere

4. CN 1- Olfactory: Sense of
Smell
• Check air movement thru ea
nostril separately.
• Smell not usually assessed
(unless sx)
– use coffee grounds or other
w/distinctive odor
(e.g. mint, wintergreen, etc)
- check ea nostril independently
- detect odor when presented @
10cm.
Hmmm..
Coffee!
Hammer & Nails icon indicates A Slide
Describing Skills You Should Perform In Lab

5. Functional Assessment – Acuity (Cranial
Nerve 2 – Optic)
• Using hand held card
(held @ 14 inches) or
Snellen wall chart,
assess ea eye
separately. Allow
patient to wear
glasses.
• Direct patient to read
aloud line w/smallest
lettering that they’re
able to see.
Hand Held Acuity Card

6. Functional Assessment - Visual
Fields (Cranial Nerve 2 - Optic)
Lesion #1 Lesion #3
Images from: Wash Univ. School
of Medicine, Dept Neuroscience
http://thalamus.wustl.edu/course
/basvis.html
NEJM Interactive case – w/demo of visual
field losses:
http://www.nejm.org/doi/full/10.1056/NEJ
Mimc1306176?query=featured_home

7. CN 2 - Checking Visual Fields By
Confrontation
• Face patient, roughly 1-2 ft
apart, noses @ same level.
• Close your R eye, while
patient closes their L. Keep
other eyes open & look directly
@ one another.
• Move your L arm out & away,
keeping it ~ equidistant from
the 2 of you. A raised index
finger should be just outside
your field of vision.

8. Pupilary Response
• Pupils modulate amount of light entering eye (like
shutter on camera)
• Dark conditionsdilate; Brightconstrict
• Pupils respond symmetrically to input from either
eye
– Direct response =s constriction in response to direct
light
– Consensual response =s constriction in response to
light shined in opposite eye
• Light impulses travel away (afferents) from pupil
via CN 2 & back (efferents) to cilliary muscles
that control dilatation via CN 3

9. Pupilary Response Testing
Technique
• Make sure room is darkpupils a little dilated,
yet not so dark that cant observe response – can
use your hand to provide “shade” over eyes
• Shine light in R eye:
– R pupil  constricts
– Again shine light in R eye, but this time watch L pupil
(should also constrict)
• Shine light in L eye:
– L pupil  constricts
– Again shine light in L eye, but this time watch R pupil
(should also constrict)

10. Describing Pupilary Response
• Normal recorded as: PERRLA (Pupils Equal,
Round, Reactive to Light and Accommodation) –
w/accommodation = to constriction occurring
when eyes follow finger brought in towards
them, directly in middle (i.e. when looking “cross
eyed”).
• Abnormal responses can be secondary to:
– direct or indirect damage to either CN 2 or 3,
– meds e.g. sympathomimetics (cocaine) dilate,
narcotics (heroin) constrict.

11. CNs 3, 4 & 6
Extra Ocular Movements
• Eye movement
dependent on Cranial
Nerves 3, 4, and 6 &
muscles they innervate.
• Allows smooth,
coordinated movement in
all directions of both eyes
simultaneously
• There’s some overlap
between actions of
muscles/nerves Image Courtesty of Leo D Bores,
M.D. Occular Anatomy: http://www.e-
sunbear.com/anatomy_01.html

12. Cranial Nerves (CNs) 3, 4 & 6
Extra Occular Movements (cont)
• CN 6 (Abducens)
– Lateral rectus musclemoves eye laterally
• CN 4 (Trochlear)
– Superior oblique musclemoves eye down
(depression) when looking towards nose; also
rotates internally.
• CN 3 (Oculomotor)
– All other muscles of eye movement – also
raises eye lid & mediates pupilary constriction.

13. CNs & Muscles That Control
Extra Occular Movements
CN 6-LR
CN 6-LR
CN 4-SO
SO ‘4’, LR ‘6’, All The Rest ‘3’
SR
IR
MR
IO SR
IR
LR- Lateral Rectus
MR-Medial Rectus
SR-Superior Rectus
IR-Inferior Rectus
SO-Superior Oblique
IO-Inferior Oblique
6 “Cardinal” Directions
Movement

14. Technique For Testing Extra-
Ocular Movements
• To Test:
– Patient keeps head immobile, following your
finger w/their eyes as you trace letter “H”
– Alternatively, direct them to follow finger
w/their eyes as you trace large rectangle
• Eyes should move in all directions, in
coordinated, symmetric fashion.

15. Function CN 5 - Trigeminal
• Sensation:
– 3 regions of face: Ophthalmic, Maxillary &
Mandibular
• Motor:
– Temporalis & Masseter muscles

16. Function CN 5 – Trigeminal
(cont)
Ophthalmic(V1)
Maxillary (V2)
Mandibular (V3)
Temporalis
(clench teeth)
Masseter (move
jaw side-side)
SensoryMotor
* Corneal Reflex: Blink when cornea touched - Sensory CN
5, Motor CN 7

17. Testing CN 5 - Trigeminal
• Sensory:
– Ask pt to close eyes
– Touch ea of 3 areas (ophthalmic, maxillary, &
mandibular) lightly, noting whether patient detects
stimulus.
• Motor:
– Palpate temporalis & mandibular areas as patient
clenches & grinds teeth
• Corneal Reflex:
– Tease out bit of cotton from q-tip - Sensory CN 5,
Motor CN 7
– Blink when touch cornea w/cotton wisp

18. CN 7 – Exam
• Observe facial
symmetry
• Wrinkle
Forehead
• Keep eyes
closed against
resistance
• Smile, puff out
cheeks Cute.. and symmetric!

19. The Ear – Functional Anatomy & Testing
(CN 8 – Acoustic)
• Crude tests hearing –
rub fingers next to
either ear; whisper &
ask pt repeat words
• If sig hearing loss,
determine Conductive
(external canal up to
but not including CN
8) v Sensorineural
(CN 8)
Image Courtesy: Online Otoscopy Tutorial
http://www.uwcm.ac.uk:9080/otoscopy/index.htm
Vestibular
CN8
Auditory
CN8
Conduction Sensorineural
Animated Ear Function: http://www.learnerstv.com/animation/animation.php?ani=313&cat=medical

20. CN 8 - Defining Cause of
Hearing Loss - Weber Test
• 512 Hz tuning fork - this
(& not 128Hz) is well
w/in range normal
hearing & used for
testing
– Get turning fork vibrate
striking ends against heel
of hand or
Squeeze tips between
thumb & 1st finger
• Place vibrating fork mid
line skull
• Sound should be heard
=ly R and L  bone
conducts to both sides.

21. CN 8 - Weber Test (cont)
• If conductive hearing
loss (e.g. obstructing
wax in canal on
L)louder on L as
less competing noise.
• If sensorineural on
Llouder on R
• Finger in ear mimics
conductive loss

22. CN 8 - Defining Cause of Hearing
Loss - Rinne Test
• Place vibrating 512 hz
tuning fork on mastoid
bone (behind ear).
• Patient states when can’t
hear sound.
• Place tines of fork next to
ear should hear it again
– as air conducts better
then bone.
• If BC better then AC,
suggests conductive
hearing loss.
• If sensorineural loss,
then AC still > BC
Note: Weber & Rinne difficult to perform in Anatomy lab due to competing
noise – repeat @ home in quiet room!

23. Oropharynx: Anatomy & Function CNs 9
(Glosopharyngeal), 10 (Vagus) & 12
(Hypoglossal)
• Uvula midline - CN 9
• Stick out tongue, say “Ahh”
– use tongue depressor if
can’t see - palate/uvula rise
-CN 9, 10
• Gag Reflex – provoked with
tongue blade or q tip - CN 9,
10
• Tongue midline when
patient sticks it outCN 12
– check strength by directing
patient push tip into inside of
either cheek while you push
from outside

24. Neck Movement
(CN 11 – Spinal Accessory)
• Turn head to L into R
hand function of R
Sternocleidomastoid
(SCM)
• Turn head to R into L
hand (L SCM)
• Shrug shoulders into
your hands

25. Motor/Strength
Anatomy and Physiology
• Impulse starts brain
• Axon (upper motor
neuron) crosses opposite
side @ brain stem
• Travels down spinal cord
specific level
Corticospinal (Pyramidal)
Tracts
• Synapses w/2nd neuron
(lower motor neuron)
• Leaves cord & travel to
target muscle
• Muscle moves
Washington Univeristy (St Louis) School of
Medicine - Dept Neuroanatomy
http://thalamus.wustl.edu/course/basmot.html

26. Muscles – Observation/Bulk
and Palpation
• Bulk (amount of
muscle mass) –
accounting for size
patient, activity level,
age – if decreased, ?
symmetric
• Palpation major
muscle groups
insight to bulk, also ?
any Inflammation,
pain
L calf hypertrophy and
R calf atrophy
L hand muscle wasting
from de-nervation

27. Muscle Tone; Observe For
Tremor
• Tone – move major joints (wrists,
elbows, shoulders, hips,
knees, feet)  range of motion
– normal  fluid
– increased w/UMN lesion; decreased
(flacid) w/LMN lesion
• Obvious tremor, unintended
movements, fasciculations:
small fibrillations muscle loss of
inervation (rare!)

28. Strength – Scoring System
Quantify with 0  5 Scale (quasi-objective)
• 0/5 - No movement
• 1/5 - Barest flicker movement not enough to
move structure to which attached.
• 2/5 - Voluntary movement not sufficient to overcome
force of gravity. E.g. patient able to slide hand across table - but
not lift it from surface.
• 3/5 - Voluntary movement capable of overcoming gravity, not any
applied resistance. E.g. patient raises hand off table, but not w/any
additional resistance applied.
• 4/5 - Voluntary movement capable of overcoming “some” resistance
• 5/5 - Normal strength
+ and – can be added to allow for more nuanced scoring

29. Specific Muscle Group
Testing
Testing of All Major Muscles is RARELY
DONE – Which muscles to check
based on clinical picture/syndrome
• Interossei of Hand – finger abduction &
adduction
• Grip strength
• Wrist - extension & flexion
• Elbow - flexion & extension
• Shoulder - abduction & adduction
Compare right to left  should be similar
(accounting for handedness).
Also must account for age, sex,
expected/appropriate strength

30. Muscle Group Testing (cont)
• Hip - flexion & extension
• Hip – abduction & adduction
• Knee - flexion & extension
• Ankle – plantar flexion & dorsiflexion
Pronator Drift: A test for subtle upper extremity
weakness.
– Have patient stand, close their eyes &
extend both hands, palm up.
– E.g. If R arm slightly weak, it will pronate
& “drift” down ward.

31. Coordination & Fine Motor Movement
• Coordinated movement depends significantly on
cerebellar input - though also requires strength,
crude motor function, joint movement, vision,
sensation, etc.
Several tests provide similar info:
Specifics:
• Finger-to-nose:
– Place your finger in space in front of patient
– Have pt move their index finger between their nose &
your finger tip
• Heel-to-shin:
– Have patient run heel of 1 foot up & down opposite
shin

32. Coordination (cont)
Specifics (cont):
• Rapid Alternating Hand Movement
– Have patient alternately touch back & then front of 1
hand against palm of other
• Rapid Alternating Finger Movement
– Have patient alternately touch tips of ea finger against
thumb of same hand
Gait & Speech (tested elsewhere) often also abnormal in
setting of cerebellar dysfunction
Normal movement is both smooth & accurate.

33. Sensory Testing
Anatomy & Physiology
• 2 main pathways: Spinothalamics & Dorsal
columns.
• Spinothalamics
– Pain, temperature, crude touch
– Impulses enter from periphery cross to other side of
cord within ~ 2 vertebral levels travel up that side to
brain
• Dorsal Columns
– Vibration, position, fine touch
– Impulses from periphery enter cordtravel up that
sidecross to opposite @ base of brainthen travel
to their terminus

34. Nerves and Their Distributions
• Specific dermatomes
not usually memorzied
– reference chart
helpful to pin down
deficits
• Distributions (& spinal
root contributions) for
specific peripheral
nerves looked up in
appropriate setting
http://academic.uofs.edu/department/pt
/students/dermatom.htm

35. Spinothalamics – Pain,
Temperature & Crude Touch
• Break Q-tip in half, creating
sharp, pointy end.
• Ask patient to close eyes
unable to get visual clues.
• Start @ top of foot.
– Orient patient by first touching
w/sharp implement, then non-
sharp object (e.g. the soft end of
a q-tip) clarifies for patient
what you’re defining as sharp &
dull

36. Spinothalamics – Pain, Temperature
and Crude Touch (cont)
• Touch lateral aspect of
foot w/either sharp or dull
tool patient reports their
response.
• Move medially across top
of foot, noting their
response to ea touch.
• Temperature tested by
touching test tubes
holding cool v warm
water against region of
interest – often omitted
for practical reasons

37. Spinothalamics – Pain, Temperature
& Crude Touch (cont)
• Light touch assessed
by gently brushing
your finger against
extremity & asking
patient (eyes closed)
to note when they feel
it
• Upper extremities
checked in same
fashion

38. Dorsal Columns - Proprioception
• Allows body to “know” where it
is in space
• Important for balance, walking
• Ask patient to close eyes
don’t receive any visual cues.
– Grasp either side of great toe.
– Orient patient as to up and
down:
• Flex the toe (pull it upwards)
while telling patient what you’re
doing.
• Extend toe (pull it downwards)
while informing them of which
direction you’re moving it.

39. Dorsal Columns – Vibratory
Sensation
• Ask patient to close eyesdon’t
receive visual cues.
• Grasp 128 Hz tuning fork by stem &
strike forked ends against heel of
your hand vibrate.
– Place stem on top of interphalangeal
joint of great toe
– Place fingers of your other hand on
bottom-side of joint
– Ask patient if they can feel vibration.
– You should be able to feel same
sensation w/fingers on bottom side of
joint.

40. Special Sensory Testing
TWO POINT DISCRIMATION (fine touch):
• 2 point discrimination (Dorsal Columns)
particularly useful when assessing for discrete
peripheral nerve injury (e.g. traumatic
disruption)
• Open paper clip  ends ~ 5mm apart
• Patient closes eyes
• Alternately touch w/1 point or 2 – normal nerve
function enables them to make distinction

41. Special Sensory Testing
(cont)
MONOFILAMENT
TESTING
• Screening test for
diabetic neuropathy
• Touch monofilament to 5-
7 areas on bottom of
foot.
• Normal =s Patient can
detect filament when tip
lightly applied to skin (i.e.
before it bends).
…Trying To Prevent This!
Sensory Testing…

42. Reflex Testing
Anatomy and Physiology
• Reflex arc made has afferent (sensory) & efferent
(motor) limb
• Synapse in spinal cord, @ which point also input from
upper motor neuron
• Disruption of any part of path alters reflexes: e.g.
– UMN lesion  reflexes more brisk (hyper-reflexia)
– LMN or peripheral sensory lesionsopposite effect (hypo-
reflexia)
• Reflexes graded 0-4+ scale: 0 = no reflex, 1+ =
hyporeflexia, 2+ = normal, 3+ = hyper-reflexia, 4+ =
clonus (multiple movements after a single stimulus)
Penn State Univ
http://www.hmc.psu.edu/sc
iweb/anat/anat4.htm

43. Reflex Basics
• Reflexes generally assessed in 5 places - 3 in
the arm (biceps, triceps, brachioradialis); 2 in the
leg (patellar & achilles)
• Basic Technique for assessing a reflex:
– Clearly identify tendon of muscle to be tested
– Position limb so muscle @ rest
– Strike tendon briskly
– Observe for muscle contraction & limb
movement

44. Reflex Basics (cont)
• Array of hammers – all effective
• Reflex Trouble Shooting:
– Make sure patient relaxed & that
you’re striking tendon directly
– Hammer swings freely
– Reinforcement (distraction) helps
if you’re having problems
• When testing legs, ask patient to pull
their hands apart as you strike
tendon
• When testing the upper extremities,
ask them to clench teeth
Example of Hyper-Reflexia:
http://meded.ucsd.edu/clinicalmed/pa
tellar_compare.htm

45. Biceps (C 5, 6)
• Identify biceps
tendonhave patient flex
elbow against resistance
while you palpate
antecubital fossa
• Place arm so it’s bent ~
90 degrees
• Place one of your fingers
on tendon and strike it
birskly
• Muscle should contract &
forearm flex

46. Triceps (C 7, 8)
• Identify triceps
tendonhave patient
extend elbow against
resistance while you
palpate above it
• Arm can hang down @
ninety degrees or have
hands on hips
• Strike tendon directly or
place finger on the
tendon & strike it
• Triceps muscle contracts
& arm extends.

47. Brachioradialis (C5, 6)
• Tendon for
brachioradialis is ~ 10 cm
proximal to wrist – you
cant see or feel it
• Place arm so resting on
patient’s thigh, bent @
elbow
• Strike firmly
• Muscle will contract &
arm will flex @ elbow &
supinate

48. Patellar (L3, 4)
• Patellar tendon
extends below knee
cap – it’s thick &
usually visible &
palpable – if not,
palpate while patient
extends lower leg
• Strike firmly on
tendon
• Muscle will contract &
leg extend @ knee

49. Achilles (S1, S2)
• Achilles tendonthick
structure connecting
calf musclesheel – if
having trouble finding,
palpate as patient
pushes their foot into
your other hand
• Hold foot @ 90 degrees
• Strike tendon firmly
• Muscle will contract &
foot plantar-flex (move
downward)

50. Babinski
• Firmly stroke bottom of
foot, starting laterally &
near heel – moving up &
across balls of feet
(metatarsal heads)
• Normal =s great toe
moving downward
• If UMN lesion (or in
newborns), great toe will
extend & other toes fan
out
Babinski Response – UMN lesion
http://meded.ucsd.edu/clinicalme
d/babinski_compare.htm

51. Gait and Romberg Testing
• Romberg: Test of balance & co-ordination input
from multiple systems: proprioception, vestibular,
cerebellum
– Ask patient to stand still w/eyes closed
– If @ risk for falling, be in position to catch ‘em (i.e. behind
them) & get help
• Gait – pay attention to:
– initiation of activity
– arm, leg movement & position
– speed & balance
Example – Gait after stroke:
http://meded.ucsd.edu/clinicalmed/walking.htm

52. Summary of Skills
□ Wash Hands
□ Cranial Nerves:
□ CN1 (Olfactory) Smell
□ CN2, 3, 4, & 6 (Optic, Occulomotor, Trochlear and abducens) –
pupils, visual acuity & eye movements
□ CN 5 (Trigeminal) Facial sensation; Muscles Mastication (clench
jaw, chew);
Corneal reflex (w/CN 7)
□ CN 7 (Facial) Facial expression
□ CN 8 (Auditory) Hearing
□ CN 9, 10 (Glosopharyngeal, Vagus) Raise palate (“ahh”), gag
□ CN 12 (Hypoglossal) Tongue
□ CN 11 (Spinal Accessory) Turn head against resistance, shrug
shoulders
Continued

53. Summary of Skills (cont)
□ Motor testing:
□ muscle bulk
□ tone
□ strength of major groups
□ Sensory testing - in distal lower & upper extremities:
□ pain/crude touch
□ proprioception
□ vibration
□ Reflexes
□ achilles
□ patellar
□ brachioradialis
□ biceps
□ triceps
□ Coordination (fingernose, heelshin, etc.)
□ Gait, Romberg
□ Wash Hands
Time Target: < 15 minutes